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Isador Lieberman
Avelino Parajon
Enrico Tessitore
Nicholas Theodore
How will technology shape spinal surgeryduring the next decade?29th April 2020 4754
The last decade proved to be a turning point in the use of advanced technologies inThe last decade proved to be a turning point in the use of advanced technologies in
spinal surgery, with developments in areas such as robotics for screw placement,spinal surgery, with developments in areas such as robotics for screw placement,
computer-assisted navigation and new techniques for minimally invasive surgery allcomputer-assisted navigation and new techniques for minimally invasive surgery all
moving forward at pace. Many believe that further technological development acrossmoving forward at pace. Many believe that further technological development across
areas such as augmented and virtual reality, endoscopic surgery and 3D printed implantsareas such as augmented and virtual reality, endoscopic surgery and 3D printed implants
will continue to change approaches to spinal surgery throughout the course of the nextwill continue to change approaches to spinal surgery throughout the course of the next
10 years. 10 years. Spinal News InternationalSpinal News International spoke to four surgeons who have led research into spoke to four surgeons who have led research into
new technologies to ask their view on the developments that will shape the aeld of spinalnew technologies to ask their view on the developments that will shape the aeld of spinal
surgery over the coming decade.surgery over the coming decade.
“If you look historically, 10 years ago there was this
underlying sense within the spine community that was very
depressed,” says Isador Lieberman (Texas Back Institute;
Plano, USA), who has been a pioneer in robotic-assisted
spinal surgery, having helped to develop SpineAssist (Mazor)
the arst robotic guidance system to have been employed in
spinal surgery. “We had been using pedicle screws for a long
time and the biggest technological advance that we saw was
the different pitch thread on the pedicle screw, or a different
tool conaguration. We just didn’t have the excitement. Over
the last ave years, with the advance and the acceptance of
navigation and robotics, all of a sudden, this excitement
came back into the spine community.”
Lieberman comments that the spinal surgery aeld is
currently at an “inhection point” regarding the use of automation within the operating theatre. “That is
going to continue to grow and continue to be a very important component of what we do surgically,” he
says, looking to the near future. He sees augmented reality as the next area for major development.
“That is coming and is going to be a huge advantage—a real change in what we are doing,” he told
Spinal News International. “When we marry the augmented reality to the navigation and robotics: I can
plan an operation, I can execute the operation, I can validate the operation, all before the patient even
gets to the operating room.”
Elsewhere, Lieberman says advances in implants and tool design, bone cutting equipment and soft
tissue removal will also lead to improvements in patient outcomes. “There are a lot of implants and
new tools that are coming out. We are getting much better with bone cutting and soft tissue removal
tools, whether it is high energy lasers or ultrasound, or ultrasonic devices. When you couple that with
augmented reality, with guidance and robotics, it just makes more sense. I can remove bone more
precisely, less tissue damage, and it protects the collateral tissue, the nerves and blood vessels. All of
those things are really, really important,“ he says.
Minimally invasive surgeryMinimally invasive surgery
“If I had to say what major technological developments will have the biggest impact on spinal surgery
throughout the 2020s,” Avelino Parajon, head of section of neurosurgery at Hospital Universitario
Ramón y Cajal (Madrid, Spain) comments, “In order of signiacance, I believe it will be: endoscopy;
expandable technology (interbody cages); robotics and augmented reality; and big data.”
Parajon, who specialises in minimally invasive surgery (MIS),
says that endoscopic spinal surgery, although not new in
concept, has only recently become more common practice
among surgeons in Europe and the USA. “It looks like MIS
surgery is moving quickly into endoscopy and this, in the very
near future, will be one of the standard approaches for the
spine across the world. Reasons for that are mainly the
increasing interest from patients, doctors and companies in
minimising the impact of the surgical approach, the great
improvements in visualisation, optics and image resolution,
and the development of curriculum and teaching activities for
endoscopy.”
Expandable technologies, in particular interbody cages, are
another area where Parajon believes advances are being made.
“They have been in the market for a long time,” he says, “but in recent years the improvement in their
design and biomechanical properties, and the increasing interest in minimising complications and
improving sagittal balance outcomes, has made them more interesting. In my opinion, the use of
expandable interbody cages will be a very common practice in the next few years.”
3D navigation3D navigation
Parajon comments that 3D nagivation has become the “standard of care” in many major healthcare
centres, because of its capacity to increase accuracy of implant placements, decreased exposure to
radiation, as well as advantages including better tumour resection and implant selection. “Robots seem
to be the next step in this evolution,” he adds. “They can improve accuracy even more and give the
opportunity to explore easier positioning of patients—for example, placing screws in LLIF surgeries in a
lateral position. Robotics combine ‘normal’ 3D navigation with robotic placement of screws.” Parajon
believes that the potential to integrate augmented reality systems into spinal procedures will “deanitely
be the next step in our spine ORs”.
Finally, and “by no means least”, says Parajon, the use of big data analytics is likely to have a profound
impact on spinal surgery in the 2020s. “This will take a little more time to be relevant in our daily clinical
practice, but probably will have more impact.
“Nowadays, surgeons are able to put screws and other implants with very high accuracy and morbidity
in big spine surgeries has decreased signiacantly with the aid of less invasive approaches. But, our
biggest challenge is still knowing the best indication for each pathology and each single patient case.
Being able to study big collections of data outcomes from different groups of patients with their own
characteristics treated by different approaches will probably give us the solution to some of these
relevant questions.”
Enrico Tessitore, deputy chairman of the Neurosurgical Unit at
Geneva University Hospitals (Geneva, Switzerland), and
president elect of the Swiss Spine Society told Spinal News
International that the continued development of robotics within
the spinal aeld will be a hallmark of the 2020s. Further evidence
of their emcacy will be crucial in advancing this push, Tessitore
said. Consequently Geneva University Hospitals is one of a
number of European centres to participate in the European
Robotic Spinal Instrumentation (EUROSPIN) study, involving
patients receiving thoracolumbar pedicle screw placement
for degenerative disease, infections or tumours. The three arms
of study will consist of robot-guided (RG), navigated (NV), or
freehand (FH) screw insertion to assess the performance of
each. “The primary outcome is not the accuracy of the screws
but the number of screws that are revised. This may have a clinical impact on patient outcome,”
Tessitore said. “We have already started to recruit subjects, and we are pretty convinced that we will
and no revised screws in the navigation and robotics cohorts.”
Furthermore, Tessitore comments that he sees the range of surgical applications for which robotic
technologies can be employed moving beyond screw placement and into more complex procedures
during the course of the next decade. He says: “I am convinced that screw insertion was the arst and
most common procedure addressed by companies developing robotics, but they have now succeeded.
Having the radiation exposure and the screw misplacement drop down to zero, this is a clear success
of the technology. Nevertheless, I am not convinced that good technology should be limited to the
screw insertion. Putting a screw in the lumbar pedicle, which is 10mm width is not a big problem—you
probably don’t need a €1 million device to put such a screw in.
“I would expect further developments in terms of some other steps of the spinal procedures. For
example, decompression. We are not that far from having robots that will be able to drill or remove
bone in the way the surgeon has planned.”
3D printing3D printing
With regards to spinal implants, Tessitore describes the continued development of 3D printing as
showing “great promise” particularly in promoting bone fusion. “Titanium 3D printed cages provide a
peculiar geometry which optimises bone ingrowth proale, but this needs to be conarmed by further
studies.” He adds that his institution is taking part in a randomised study involving 3D printed interbody
cages from the Swiss manufacturer Spineart. “We perform a very early SPECT-CT scan in order to see if
there is an early integration of these cages. Compared to PEEK cages, for example. 3D printing
technology seems to promote fusion by facilitating ingrowth of bony cells from the endplates into the
cage.”
Tessitore also pointed to developments in endoscopic surgery as another area for growth. He said:
“There have been big developments in terms of endoscopic devices. Joimax and Richard Wolfe (RIWO)
are investing a lot in new endoscopes. I have been really impressed with the improvements in optics
and image resolution, amelioration of working channels, and creation of dedicated instruments, like
rongeurs and drills, which was not the case with the earlier generation of endoscopes.”
For Nicholas Theodore, professor of neurosurgery at the Johns Hopkins University School of Medicine,
and director of the Neurosurgical Spine Center of Johns Hopkins Medicine (Baltimore, USA), “the
intersection of engineering and spinal surgery” is the trend he expects to see in the coming decade.
Theodore is himself a pioneer in robotics in spinal surgery, having invented the Excelsius (Globus
Medical) spinal surgery robot.
“Spinal surgery meets engineering”“Spinal surgery meets engineering”
He sees the further integration of image guidance technology,
alongside robotics as having a major impact in future. “When we
look at the data, it is quite clear. If you utilise screws in just
freehand, your accuracy rate is about 70%. That increases to the
low nineties when you start using X-ray, and the high nineties
when you start utilising image guidance. We have this data, so
why aren’t people using it? The majority of screws that are not
perfectly placed are usually harmless. If it doesn’t cause harm to
the patient, then we are not jumping up and down about that.
Then you add robotics in and that has changed everything now,”
he comments. “The whole concept of utilising robotics with
image guidance is that we can reliably and quickly get to a point
where the robot can take us to any trajectory that would be
impossible with X-ray in a very rapid and very precise fashion.”
Despite being a pioneer in the aeld, Theodore does not see robots replacing the role of the surgeon
entirely, although he does concur that increasing applications of the technology will create a further
demand for robotics in the OR. “The robot is not going to replace the surgeon,” he says. “It is also not
going to take a bad surgeon and make them good. But, it certainly could take a good surgeon or an
adequate surgeon and make them much better.” On future applications for the technology, he adds:
“When we start introducing drills to be able to cut bone and jig bone, that will be the next step. I will go
out on a limb and say that will also be able to be planned. In other words, the robot can pick the best
site to do the osteotomy, for instance for scoliosis cases. It will take you to that position, you put the
drill in, or the bone scalpel and you remove the bone yourself to do that. But in the fraction of the time
that we are taking to do it freehand, for instance.”
Patient safety and improving outcomes from robotic-assisted surgeryPatient safety and improving outcomes from robotic-assisted surgery
Although cost is recognised as a barrier to wider adoption of robotics in spinal surgery, Theodore
argues that this should be offset by potential beneats in patient safety and outcomes. “First and
foremost,” he says, “it is about patient safety. Can we improve our outcomes through the use of this
technology? By avoiding one misplaced screw into the spinal canal that causes a neurologic injury, the
robot has paid for itself. And, you also have the ability to place hardware more accurately. If you revise
something intraoperatively you have already made the mistake. Prevention is better.”
A robot-assisted spine surgery
Beyond robotics, 3D printing is another area that Theodore sees advancing in the spinal surgery arena.
“3D printed implants,” he says, “I think, are very exciting. I don’t know if it is going to change the world,
but it is another example of engineering and surgery where we are able to make a device with this 3D
printed surface that allows bony ingrowth so that the fusion is easier than having to pack in bone, or to
use chemicals like bone morphogenic protein, where you probably eliminate the usage of that through
various technologies.”
Theodore also believes that employing data analytics in the spine theatre will create further beneats.
He details a project being undertaken at Johns Hopkins, titled Spine Cloud, that is working towards this
aim. “This involves utilising imaging, patients images throughout the course of their disease process,
before and after surgery. We will be utlising data from the electronic medical record and then also
patient reported outcomes, to predict who is going to do well and what surgeries work and what
surgeries don’t.” The outcome from this, Theodore says, will be the ability to specify a set of patient
parameters at the beginning of a treatment process, which are input into a software programme. These
parameters can then be measured against data from outcomes of previous surgeries, allowing the
software programme to predict how a patient will respond to a particular procedure. Theodore
concludes: “This whole ability to predict how we are going to do it all, and also inform us of what might
be the best procedure for any given patient is. To me that is mindblowing.”
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Learning curve in robot-Learning curve in robot-assisted spinal fusion mayassisted spinal fusion maybe associated with inferiorbe associated with inferioroutcomesoutcomes
Meta-analysis ands higherMeta-analysis ands higherrate of accuracy in roboticrate of accuracy in roboticpedicle screw placementpedicle screw placement
Technology and the changingTechnology and the changingrole of the spine surgeonrole of the spine surgeon
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